Some Providers Shifting Away From Nurses for Home Care

Rich Daly, HFMA Senior Writer/Editor

Some providers and health plans have started using nurses as one component of a team that monitors and coordinates the provision of home health services.

May 4—Some health systems are replacing nurses with low-cost personnel as they expand their delivery of home-based services.

Ascension Health has moved away from using nurses in its home healthcare services and has begun using other allied healthcare workers, whom it refers to as “health partners.” Among those positions is a new category of employee called “health promoters,” who might not have a clinical degree.

“The skills needed and the care that we want to deliver are not based on what the letters are after your name—they are based on other things,” said Jordan Asher, MD, chief clinical officer at Ascension Care Management. Now, the system asks, “What is the job that we need physicians to
do? What is the job that we need nurses to do? What’s this other job that we have to create a whole new group of people to do?”

Ascension’s approach to home care entails moving from a standard clinical model to much more of a public health model, according to Asher.

“You ask, ‘What is the job that needs to get done and then who are the best people to do that job—without talking about any titles,’” Asher said in an interview. “I completely agree with that.”

A Team Approach

Paul Casale, MD, an executive director for NewYork Quality Care, the accountable care organization of NewYork-Presbyterian, said his organization has used home health nurses for patients who are transitioning out of the hospital. During visits, the nurses use smartphones to set up telehealth
visits between at-risk patients and care managers and hospitalists, allowing those individuals “to see what’s going on in the home” following a discharge.

“Do they have the resources they need at home, whether it’s food in their refrigerator, making sure that they have their medicines, that they understand the medicines they take?” Casale said at this week’s World Health Care Congress.

After the assessments, the care manager takes over, he said.

“It’s a way to transition them from the hospital to then bring them back into their primary care and using telehealth, where previously they were sort of lost a bit in the system,” Casale said.

John Bulger, DO, chief medical officer of Geisinger Health System, said his organization targets high-risk heart failure patients after discharge by providing them with blue tooth-enabled scales along with access to a care manager or community health assistant. The health system has published data showing
that the combination of technology and personnel has significantly decreased readmission rates among the patients.

“Essentially it’s an early-warning system where you can use technology and understand when the patients are getting in trouble, and you can either bring them to a primary care physician or have a home nurse go out and see them and treat them before they get in that spiral where they use the
emergency room,” Bulger said.

The ability to perform remote monitoring and home visits allows the provider to “get the patient the care they need when they need it and where they want it,” Bulger said. “When they don’t get seen, that’s when they get into the spiral and end up in the emergency room and end up in the hospital,
which is a higher-cost piece of it.”

Benefits of Nurse-Led
Programs

Others continue to find an important home health role for nurses.

Adam Myers, MD, CMO of Texas Health Physicians Group, said his system built a care-transitions house calls program using nurse practitioners after its Medicare Advantage plan found too many readmissions among subsets of patients. The nurse practitioners see the targeted high-risk
patients in the patients’ homes within 72 hours of discharge.

“And primarily the focus is on how they’re doing, vital signs, safety of the home environment, ‘Do you have the food that you need, do you have your medications, do you know what medications you still need to take?’” Myers said. “It’s one thing to have your meds reconciled when you’re in
the hospital; it’s another thing to pull all of the meds out of the cabinet and the bags and the cubby holes and the drawers and put them all on the kitchen table and then reconcile those medications.”

The program was credited with cutting readmission rates for the targeted patients.

Chet Burrell, president and CEO of CareFirst Blue Cross and Blue Shield, said his organization identified a need among the sickest patients, who had multiple chronic diseases and the highest hospitalization rates, for home visits and care coordination by nurses to supplement the work of primary
care physicians.

“Where do you break down? At home. Where do you not comply? At home. Where do you get confused? At home,” Burrell said. “Nobody goes into the home.”

Some providers and health plans have started using nurses as one component of a team that monitors and coordinates the provision of home health services.

May 4—Some health systems are replacing nurses with low-cost personnel as they expand their delivery of home-based services.

Ascension Health has moved away from using nurses in its home healthcare services and has begun using other allied healthcare workers, whom it refers to as “health partners.” Among those positions is a new category of employee called “health promoters,” who might not have a clinical degree.

“The skills needed and the care that we want to deliver are not based on what the letters are after your name—they are based on other things,” said Jordan Asher, MD, chief clinical officer at Ascension Care Management. Now, the system asks, “What is the job that we need physicians to
do? What is the job that we need nurses to do? What’s this other job that we have to create a whole new group of people to do?”

Ascension’s approach to home care entails moving from a standard clinical model to much more of a public health model, according to Asher.

“You ask, ‘What is the job that needs to get done and then who are the best people to do that job—without talking about any titles,’” Asher said in an interview. “I completely agree with that.”

A Team Approach

Paul Casale, MD, an executive director for NewYork Quality Care, the accountable care organization of NewYork-Presbyterian, said his organization has used home health nurses for patients who are transitioning out of the hospital. During visits, the nurses use smartphones to set up telehealth
visits between at-risk patients and care managers and hospitalists, allowing those individuals “to see what’s going on in the home” following a discharge.

“Do they have the resources they need at home, whether it’s food in their refrigerator, making sure that they have their medicines, that they understand the medicines they take?” Casale said at this week’s World Health Care Congress.

After the assessments, the care manager takes over, he said.

“It’s a way to transition them from the hospital to then bring them back into their primary care and using telehealth, where previously they were sort of lost a bit in the system,” Casale said.

John Bulger, DO, chief medical officer of Geisinger Health System, said his organization targets high-risk heart failure patients after discharge by providing them with blue tooth-enabled scales along with access to a care manager or community health assistant. The health system has published data showing
that the combination of technology and personnel has significantly decreased readmission rates among the patients.

“Essentially it’s an early-warning system where you can use technology and understand when the patients are getting in trouble, and you can either bring them to a primary care physician or have a home nurse go out and see them and treat them before they get in that spiral where they use the
emergency room,” Bulger said.

The ability to perform remote monitoring and home visits allows the provider to “get the patient the care they need when they need it and where they want it,” Bulger said. “When they don’t get seen, that’s when they get into the spiral and end up in the emergency room and end up in the hospital,
which is a higher-cost piece of it.”

Benefits of Nurse-Led
Programs

Others continue to find an important home health role for nurses.

Adam Myers, MD, CMO of Texas Health Physicians Group, said his system built a care-transitions house calls program using nurse practitioners after its Medicare Advantage plan found too many readmissions among subsets of patients. The nurse practitioners see the targeted high-risk
patients in the patients’ homes within 72 hours of discharge.

“And primarily the focus is on how they’re doing, vital signs, safety of the home environment, ‘Do you have the food that you need, do you have your medications, do you know what medications you still need to take?’” Myers said. “It’s one thing to have your meds reconciled when you’re in
the hospital; it’s another thing to pull all of the meds out of the cabinet and the bags and the cubby holes and the drawers and put them all on the kitchen table and then reconcile those medications.”

The program was credited with cutting readmission rates for the targeted patients.

Chet Burrell, president and CEO of CareFirst Blue Cross and Blue Shield, said his organization identified a need among the sickest patients, who had multiple chronic diseases and the highest hospitalization rates, for home visits and care coordination by nurses to supplement the work of primary
care physicians.

“Where do you break down? At home. Where do you not comply? At home. Where do you get confused? At home,” Burrell said. “Nobody goes into the home.”

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